Patients w/ abnormal Pap smear are referred for colonoscopy to screen for presence of cervical cancer.
Colposcopic exam should include inspection of the transformation zone, definition of the extent of the lesion & biopsy of the most abnormal area for tissue diagnosis.
The earliest stages of cervical carcinoma are generally asymptomatic.
Watery vaginal discharge & postcoital bleeding or intermittent spotting may be present & are usually unrecognized by the patient.

Radiotherapy

Stage IA1

Postoperative pelvic radiotherapy with or without Cisplatin-containing chemotherapy should be considered in patients with at least 2 high-risk factors (ie lymphovascular invasion, deep stromal invasion, large primary tumor)

Patients with positive surgical margins, parametrial involvement or pelvic node involvement should be treated with post-op pelvic external beam radiation with concurrent Cisplatin-containing chemotherapy with or without vaginal brachytherapy

Concomitant chemoradiation may utilize Cisplatin as single agent or Cisplatin with 5-Fluorouracil

Dose is based on summation of conventional external-beam fractionation and low-dose rate (40-70 cGy/hour) brachytherapy equivalents

Dose should be modified based on normal tissue tolerance

Brachytherapy is an important part of radiotherapy for cervical carcinomas

It treats mainly the primary tumor

The surrounding tissue can be relatively spared while high doses of radiation are delivered to the tumor

Delivery is through manual or remote after-loading techniques

If brachytherapy is not available in limited-resource settings, extrafascial hysterectomy or its modification may be performed in patients with residual tumor found 2-3 months after concurrent chemoradiotherapy and additional boost

Stage IB1 or Stage IIA1

Patients with stage IB1 or stage IIA1 may be treated with pelvic EBRT plus brachytherapy (point A dose: 80-85 Gy)

Should be modified based on normal tissue tolerance

When using high dose-rate brachytherapy, define the doses according to biological equivalence

Combined radio-surgery, which represents a therapeutic option, consists of pre-op brachytherapy followed by surgery

Advanced Tumors

Concurrent chemoradiation represents the standard treatment

Has been shown 30-50% decrease in the mortality risk compared to radiotherapy

In patients undergoing primary chemoradiation, the volume of radiotherapy is critical and is guided by assessment of nodal involvement in the pelvic and para-aortic nodes

Patients with advanced stage IB2-IIA/B may benefit more from chemoradiotherapy than patients with stage III and IVA

Based on trials done, it translated to a 5-year survival benefit of 10% for patients with stage IB-IIA, 7% for patients with stage IIB and 3% for patients with stage IIIB-IVA

With low-dose rate intracavitary systems, total doses from brachytherapy and external-beam radiation to point A of at least 80 Gy are recommended particularly for small tumors; whereas for larger tumors, doses of 85 Gy or higher is recommended

Inguinal lymph nodes should be treated in patients with lesions in the lower 1/3 of the vagina

Treatment of occult or macroscopic para-aortic lymph node disease using extended-field EBRT should be carefully planned so that adequate dose (45 Gy for microscopic disease) is given without exceeding bowel, spinal cord, or renal tolerances

Patients with positive para-aortic lymph nodes after surgical staging should undergo further screening with CT or PET scan

Once indicated, biopsy of suspected areas should be considered

If positive for distant metastases, they should be treated with chemotherapy and individualized radiotherapy

In basic-resource settings, neoadjuvant chemotherapy may be given to patients with larger tumors or advanced cancer to shrink the tumor prior to hysterectomy

Determine whether radiotherapy or surgery may be utilized for patients with local recurrence after initial treatment

Survival rates of approximately 40% have been reported

Salvage pelvic radiotherapy may be offered to radiotherapy-naive patients with local recurrence

Individualized EBRT and chemotherapy with platinum-based agent(s), with or without brachytherapy, may be recommended in the following patients: With local or regional recurrence but without previous radiotherapy, and with recurrences outside of the previously treated radiotherapy field

Surgical resection may be considered

Central Recurrence

Patients with central recurrence after radiotherapy may benefit from pelvic exenteration, with or without intra-operative radiotherapy (IORT)

Patients will benefit from pelvic exenteration if rehabilitation programs dealing with psychosocial and psychosexual issues are available

Reconstructive procedures should also be available

Radical hysterectomy or brachytherapy may be an option in very few selected patients with small central lesions of <2 cm

Noncentral Recurrence

The following options may be utilized:

Resection with or without IORT for close or positive margins

Individualized EBRT with or without chemotherapy

Chemotherapy

Best supportive care

Participation in clinical trials

Patients who recur after 2nd-line therapy, such as radiotherapy or surgery, have a poor prognosis

Chemotherapy, supportive care, or participation in clinical trials are the treatment options for these patients